A nurse is caring for an unresponsive client who is not breathing and has no pulse. What is the correct compression rate for BLS chest compressions in this situation?

A) Correct. The first step in recognizing cardiac arrest is to assess the client's level of responsiveness. If the client is unresponsive, the nurse should proceed with assessing for the absence of breathing and a pulse.

B) Incorrect. While cyanosis may be a sign of decreased oxygenation, it is not the first step in recognizing cardiac arrest. Assessing responsiveness is the primary step.

C) Incorrect. Asking about chest pain may be important in assessing other cardiac conditions, but it is not the first step in recognizing cardiac arrest.

D) Incorrect. Determining the client's blood pressure reading is not the first step in recognizing cardiac arrest. Assessing responsiveness is the initial priority.

A) Correct. In the event of an unresponsive individual with no breathing and no pulse, the nurse's immediate action is to activate the emergency response system and retrieve the AED. Early access to the AED can significantly improve the chances of survival for the client in case they are experiencing a shockable rhythm.

B) Incorrect. Chest compressions should be started immediately after identifying an unresponsive individual with no pulse. The rate of compressions should be 100 to 120 compressions per minute, not 60.

C) Incorrect. The current guidelines recommend starting with chest compressions, not rescue breaths, when assessing an unresponsive individual without a pulse.

D) Incorrect. Time is critical during a cardiac arrest, and the nurse should not wait for additional healthcare providers before initiating CPR and activating the emergency response system.